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1� A <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORL14A '1F,�N 1-' TP.L HEN TH <br /> TYPE OF ACTION ❑ 1 11 %\ I4:RMIT ❑ 5.C1I ANGE OF INFORMATION E17 PERMANENT FACILI'T'Y CLOSURE d00 <br /> (check ana Iran onlvl ❑ , - <br /> 3.12ENEWAL.PERMIT El6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFGR PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL.NUMBER OF UST's Ar FACILITY ... P:\C'I l.fl'Y ID k <br /> ONE .Ieo 11'ce Udty — <br /> BUSINESS NAME(snnl,m FACJLM NAME-DBA-Ming anslnoS,ASI - <br /> Miles Trust Properly <br /> BUSINESS SITE ADDRESS H''3 CITY ^� <br /> 1940 South American Street,Stockton,CA 95207 <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DIsTR113Uf]ON 101 Is the facility located on Indian R,senation or 40' <br /> ❑ 3. FARM ❑ 4.PROCESSOR ❑ 6.OTIICR "frust lands? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 1.7. PIIONE 409 <br /> Loy and Frances Miles Trust 209 007-54-79- zj•S••(L <br /> MAILING ADDRESS <br /> 6333 Pacific Avenue.9366 <br /> Cll'Y Stucktnn.CA 95207-3713 41^ I STA'T'E 411 ZIP CODE 413 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERA'T'OR NAME 4291 PHONE 4'3' <br /> Loy and Frances Miles Trust 209 507-5i99. 5Z <br /> 1AA1LING ADDRESS 4'-s-s <br /> 6333 Pacific Avenue.k366 <br /> C'I'TY 4=8-4 STATE 42-R-` ZIP CODE 42St. <br /> Stockton.CA)5207-3713 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NANIF :14 PHONE "us <br /> Loy and Prances Miles'I'rust ( 209 507-54 :it �r5JL <br /> MAILING ADDRESS 410 <br /> 6333 Pacific.Avenue.4366 <br /> CITY Stockton,CA 95207-3713 al%. STATE 415 ZIPCODE 41 <br /> OWNERTYPE: ❑ 4.LOCALAGENCYIDIS-1RIC"f ❑ 5.COUNTYAGENCY ❑ 6,SIA fE AiNCY 4'0. <br /> ❑ 7.FEDERAL AGENCY n(3.NON-GOVERNMENT' <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> _I <br /> TY (TI{) HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,it durc arc questions. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to I.FACILITY OWNER '-' <br /> P - ® �] 4.TANK OPERATOR <br /> 1I 3.TANK OWNER © 5.FACI I.IT"Y OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION.OR OFFICE(Required For Public rAaencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIP ATION: 1 certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APP SIGN DATE 4224- PHONE 4"- <br /> AP <br /> lC NAM (print) 426 APPLICANTTITLE 441 <br /> Reba Veltri Trustee <br /> UPCF UST-A Rev.(1212007) <br />